Panic Disorder Screening Form

This is a screening tool to help you determine whether you might have Generalized Anxiety Disorder that needs professional attention. This screening tool is not designed to make a diagnosis but to be shared with Summit Behavioral Health mental health professional to inform further conversations about diagnosis and treatment. One of our providers will perform a free review of your form and contact you to discuss potential care options

INSTRUCTIONS

1) Fill and submit shown form

2) Choose if you want to be contacted by Summit BHP staff

3) Select date/time for brief virtual meeting

Date *

Date

Repeated or unexpected “attacks” during which you suddenly are overcome by intense fear or discomfort for no apparent reason

If yes, during an attack did you experience any of these symptoms?

	Response
Pounding heart
Sweating
Trembling or shaking
Shortness of breath
Choking
Chest pain
Nausea or abdominal discomfort
"Jelly" legs
Dizziness
Fear of losing control or "going crazy"
Fear of dying
Numbness or tingling sensations
Chills or hot flushes

As a result of these attacks, have you

	Response
experienced a fear of places or situations where getting help or escape might be difficult, such as in a crowd or on a bridge?
felt unable to travel without a companion?

For at least one month following an attack, have you

	Response
felt persistent concern about having another one?
worried about having a heart attack or “going crazy”?
changed your behavior to accommodate the attack?

Having more than one illness at the same time can make it difficult to diagnose and treat the different conditions. Depression and substance abuse are among the conditions that occasionally complicate panic disorder

	Response
Have you experienced changes in sleeping or eating habits?

More days than not, do you feel

	Response
sad or depressed?
disinterested in life?
worthless or guilty?

During the last year, has the use of alcohol or drugs

	Response
resulted in your failure to fulfill responsibilities with work, school, or family?
placed you in a dangerous situation, such as driving a car under the influence?
gotten you arrested?
continued despite causing problems for you or your loved ones?

Do you consent to Summit BHP contacting you to discuss results and care options?

Appointment

Name

First Name Last Name

Age

Gender

Phone Number

Area Code Phone Number

Summit Behavioral Health

2115 County Road D East, Suite C-100, Maplewood, MN 55109

Ph: 651-358-7020 www.SummitBHP.com